Trajectory of Positivity- Psychiatric Social Work in North East

Sonia P Deuri and Sobhana H

ABSTRACT: The North Eastern Region of India has been a grossly neglected part in the Indian Territory. It is only recently that the Indian Government has initiated a Look North East Policy, recognising the special needs and strategic concerns of this region. The geo, socio and political conditions of North East places certain unique health and mental health challenges. The mental health service providers face huge challenges while addressing these issues. It is with this back drop that the present paper traces the trajectory of positivity through the Psychiatric Social Work services. The history of Psychiatric Social work in LGB Regional Institute of Mental Health, Tezpur, the services rendered by the Department and the challenges faced will be presented.

Introduction
The north-eastern states comprise of Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Tripura and Sikkim. Clubbed together as NER, they border Nepal, Bhutan, China, Myanmar and Bangladesh. The North East region covers an area of 2, 55,000 sq. km and extends from the tip of the Himalayas to the Malaysian peninsula. The total area covered by this region is 7.7 percent of the geographical area of the country. With a total population of 39.04 millions which is 3.8 % of the country’s population, the region is mostly isolated from the rest of India, both geographically and economically. North East India is a region with strong natural and human resources. However, it has remained backward even after fifty three years of Independence. The region has a poor economy and connectivity remains a problem. The cultural, social and economic contrasts of this region also make it unique since it is situated in - between the two great traditions of the India Asia and Mongoloid Asia. This region is officially recognized as a special category of states. The nodal agency that is responsible for the economic and social development is The North East Council (NEC) which was constituted in 1971, later the North Eastern Development Finance Corporation Ltd (NEDFC) was incorporated on August 9, 1995 and the Ministry of Development of Northeastern Region (DONER) was set up in September 2001.

Socio-Political issues
The North-east has been added to political India only in recent times. The isolation of the Northeastern states traces back to the British era, when as a result of British imperialism, the region was cut-off from its traditional trading partners (Bhutan, Myanmar and Indo-China). In 1947 Indian independence and partition made this a landlocked region. Soon it became a captive market for mainstream India. Ethnically, the Northeast has a large Mongoloid population, with cultural and population sources that are different from mainstream India. The northeastern states with just 25 out of a total of 543 seats in the Lok Sabha are politically insignificant in Delhi. This has kept the Northeast politically and culturally apart from the rest of India. The region is known for its unique culture, handicrafts, martial arts, and scenic beauty.
Problems include insurgency, unemployment, drug addiction, and lack of infrastructure. Since the beginning of the economic liberalization in the 1990s, studies have shown that this region is lagging behind the others in terms of development.
Militancy in the North-East is a complex issue. The causes of this are multifold. A largely tribal society has changed to a modern society with no means to sustain the benefits of this change. The long porous borders provide easy movements of militant groups and the inflow of illegal arms into the region. Besides this, it also facilitates large scale influx of illegal migrants into the country. Lack of employment opportunities other than in the Government sector has fuelled the influx of neo-literate youth into militancy.
Today, militancy in NER has assumed serious dimensions and has affected the very functioning of the democratic State. There is large scale disruption to life, killings and extortion that has repercussion in overall mental health scenario of this region.
Despite having vast potential resources, the north east region stands much below the national average in terms of developmental indices. Fifty years of planning in the country has made very little change, if any, in the socio-economic life of the region. All these have led to a widespread feeling of neglect.Mental Health in NER:
Mental Health research is largely neglected area in the North East. Major problem for conducting such studies in this region are:
1. Low priority to Health government policies; mental health is unheard of till recently.
2. The huge diversity in the population with regard to dialect, language, rituals, cultures and belief systems with little in common.
3. Widespread prevalence of superstition , misconception and stigma
4. Ignorance , poverty and illiteracy
5. Poor infrastructure of general health care
6. Poor access to health care (general and mental health care)
7. Lack of trained human resource
Mental illnesses have been considered to be possession by god, spirit, supernatural power etc. and were treated by various forms of faith healing. The faith healers are very popular among rural folk even today and they can cure various forms of mental illnesses mostly of dissociative nature with their indigenous methods.
The dependence on faith healing also led to phenomena like witch-hunting. Even now there are sporadic incidents of killing innocent people for suspicion of causing illness by witchcraft. This is particularly common in some tribal community and tea tribes. Though the modern treatments of mental illness are getting increasingly available and acceptable for the people of this region, this development is at a very slow pace.Mental Health services
The land mark in the history of mental health service of this region is the establishment of ‘Mental Asylum’ at Tezpur in 1876 by the Imperial Government. Since Independence the erstwhile hospital has been under the administrative control of the Home Ministry, Health and Family Welfare Department of Govt. of Assam, Board of Administrators, North Eastern Council, DONER, and finally under the Ministry of Health and Family Welfare, Govt. of India, the Institute has come under the category of Institute of Excellence for the region.
Some of the other mental health service facility of this region:

There are very few NGOs working with the mentally ill.
The availability is not in keeping with the population pattern. Moreover the facilities are unevenly distributed. The main psychiatric facility is located at Tezpur, Assam (LGBRIMH) .It is the only Institution catering to the whole of North Eastern region.

Mental Health Manpower in NER
The region is also deficient in mental health manpower. The following table shows the approximate number of mental health professional in the North Eastern Region. There is no authentic data in this regard. The current data is a compilation from Dr. Murthy’s article of 2006 and existing network of professional. This is not an accurate data but more less reflects the distribution of mental health professionals.

Apart from inadequate treatment facilities, the mental health services are unequally distributed in the northeastern states. With this backdrop we now trace the evolution of Social Work and Psychiatric Social work in this region.

Social Work & Psychiatric Social Work in North East
Social work as an academic discipline was born in 1997 when Assam University started an integrated programme of 5 years. The department runs Five Year Integrated Course in Social Work which leads to BSW (three years) and MSW (two years) Degrees. Later MSW programme started in the year 2002 at Mizoram University. The department was initiated initially at NEHU, Shillong. Martin Luther Christian University, Shillong, a newly established private Tribal University started the MSW programme in the year 2006. The Bosco Institute, Jorhat started MSW programme in the year 2008 under the Dibrugarh University. Recently, National Education Foundation, Guwahati, a private organization, also started MSW programme under the Dibrugarh University.
Psychiatric Social Work Services had its inception in north east at the department of Psychiatry when a Psychiatric Social Worker got appointed after a long struggle in the year 1991. Here the incumbent had to ward off competion and politicking from varied social scientists to get an appointment. The year 2000 saw yet again the struggle of a Master holder in Social Work in getting accepted for the same post. The year 2007-08 was ironical in many ways at the Department of Psychiatry. On one hand the incumbent Psychiatric Social Worker (with P G in Social Work) was sent for higher training to NIMHANS and on the other hand untrained personnel from Anthropology was appointed in a Psychiatric Social worker in a newly created post. Multiple appeals to the esteemed educationists and Professional organizations in Social Work did not see any proactive action from any quarters. The question comes to mind – what is role of a professional organization in reality? Is the formation of regional pressure forums the answer to inactivity of National professional organizations?
The development of Psychiatric Social Work Assam should also be seen in the context of the development of LGBRIMH, Tezpur. Lokapriya Gopinath Bordoloi Regional Institute Mental Health,Tezpur, Assam (LGBRIMH) has been providing treatment to the mentally ill from Assam and far-flung North Eastern States of India since many years. State of Assam was carved out of the Bengal province in 1875 to meet the needs and aspirations of the local people. It was in 1876, that the Mental Asylum was set up in Tezpur to cater to the needs of the mentally ill from Greater Assam. In 1898, the care & responsibility of the “Asylum” was given to a medical person; thus beginning an era of medical care for the mentally ill. The Hospital came to lime light in 1962 when Tezpur town was vacated during the Chinese aggression.
The Honourable Supreme Court in 1994, following an enquiry, envisaged wide spread recommendation in mental health services development in the state of Assam. The recommendations stipulated the improvement and up gradation of the LGBIMH, Tezpur towards making it into a Regional Resource Center in Mental Health.
In accordance with recommendation of the Commission and Honorable Supreme Court rulings thereof, this Institution came under the interim Board of Administrators for period of three years. Following that, North Eastern Council, Shillong, took over the Institute on 17th February’ 1999 from the Government of Assam. The Institute is hence named the Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur. As of now the Institute has been taken over by the Ministry of Health and Family Welfare, Govt. of India from the 1st of June 2007.
The first Psychiatric Social Work professional joined the Institute in January1998 in the capacity of Asst. Professor in Psychiatric Social Work, thus eventually paving the way for a department of Psychiatric Social work. Though the department’s primary objective was to initiate and develop teaching programs, was also focusing on organizing various psychosocial services in the Institute. This was a part getting together a Multidisciplinary faculty in Mental Health at the Institute in order to get started with the Academic activity to develop man power in mental health. The appointments were made in pursuance of Supreme Court orders for up gradation of the erstwhile Mental Hospital to a Teaching Hospital in the year 1994-96.
Various Psychiatric Social Work services were planned while supporting the starting of teaching programmes that was to be initiated for manpower development in Mental Health for the region.
As the initiative towards developing human resource for mental health services, the faculty of PSW was part of the training team of all nursing and auxiliary staff of the Institute during the year of 1998- 99. In the meanwhile, psychosocial services in the OPD and indoor were also started. These services included Community services, Day care services, Free medicine service, Case work , Group work Services etc . This continued till 2001 when an additional duty was allotted to the faculty of PSW. She was made a member of the team that initiated the DPN course started in the year 2001. This was also the year when the Department of Psychiatric Social Work, stepped out of the confines of the hospital system and trod into the community. The Community Mental Health was initiated at Biswanath Chariali in the year 2001 where the mental health team went on a monthly visit to make mental health more accessible for people. In the mean time, as the teaching departments in the institute were not in position to start regular programmes, the departments also initiated various exposure training to students of Nursing ,Psychology, Philosophy, Education and Social Work and NGO personnel. With the clinical services in place, the department now had to focus on manpower development in Psychiatric Social Work. In order to do that, in the year 2002, proposals were sent to all the Universities in North East to start a formal training course in M Phil in PSW. None of the universities responded positively. To make them understand the nature of the profession and its requirements were an uphill task. Finally, it was only in the year 2003 after much persuasion that the syllabus got approved in the Syllabus Committee of Gauhati University.
Convincing the University in accepting a professional course in Social Work was in fact an extremely trying, challenging and stressful task. The officials had to be educated about Psychiatric Social Work and its requirements each and every time personnel visited the University. Liaison activities with the University had to be a fortnightly routine that involved astute inter departmental networking skills.
Inspection for the course was undertaken in 2004.The arduous task of getting the permission for the course seemed a reality but the lack of adequate manpower led the University to recommend postponing of starting the course as the requirements were assessed as per UGC norms in view of non-existent norms by Councils of Professional bodies. The Inspection team failed to recognize that the course is viable in a Multi-disciplinary set-up. This is an indication of the huge lacunae in the professional social work. The absence of a Social Work Council in fact hampers the recognition of the course in regions where it is hardly heard of and appreciated. To this day Anthroplogists, Sociologists and Psychologists get appointed in the post of Psychiatric Social Workers.
These however did not make any dent in the efforts taken to place Psychiatric Social Work as a force to reckon with in the mental health services. So, in the clinical front, free medicine services were introduced in OPD through the advocacy initiated by the department in 2003.
Meanwhile, in an attempt to strengthen the presence of the profession, multiple attempts were made towards acquiring faculty and Supervisory man power for the department from the year 2004 onwards. The sociopolitical condition of the state and its poor infrastructure discouraged trained professionals to take up their career here.
Also in the same year, Department of Psychiatric Social Work introduced the Rehabilitation Services at the Institute and started Day care services for the female boarders from indoor and outdoor. This was followed by a male activity centre in the year 2007 for the indoor patients. Re - Integration of long stay patients has been one of the priority areas that the department has started. Over the last 10 years 75 patients have been reinstated back to their families.
Not to let down by the difficulties faced from all quarters, the department also took a major initiative for organizing and starting of the NMHP funded Community Project in 2006-07 at the Sootea Block in Sonitpur District . The initiative has resulted in 1000 patients being identified and treated. The department has initiated Self Help group formation among three groups and 6 such groups are in the pre formation stage. Community work in the area is an ongoing activity of the department and has also been in cooperated into the M. Phil clinical curriculum.
The year 2007-08 was a new beginning with joining of 3 Psychiatric Social Workers. The presence of newly appointed staff gave new impetus for starting of the academic training in Psychiatric Social Work apart from the range of Psychiatric Social Work services at the indoor, outdoor and Community set-ups. Following the routine procedure of re- inspection, ratification by various Committees and Research Council at the University, finally after years of intense struggle with the university officials, the permission to start the 2 year course was given in Dec 2008. It even involved the department seeking the intervention of the Governor of the State of Assam (who was also the Chancellor of the University and the erstwhile Chairman of the Board of Governors of the Institute) to expedite matters. The arduous journey of starting a teaching program took almost a decade of groundwork and lots of determination and positivity.
The M Phil course got underway on May 2009 with 2 students. The 2nd year of the program saw 2 seats going vacant. Though the department is only in the 2nd year of formal academic activity, it has already conducted 4 entrances with all due governmental procedures, to fill up seats. The effort involved in getting the departments and fresh Social workers in the Eastern sector of India to see the need for clinical training in Psychiatric social work was one of persuasion, liaison and sheer hard marketing. This is an indication that takers for higher education in Psychiatric Social Work is hard to come by. Even though Assam has a projected estimated population of 2.7 lakhs with major psychiatric illnesses, it is yet to be prioritized as an area of attention by health policy makers. As there is no health or Mental Health policy it is yet to become a viable motivating factor for the youth of the land to opt for a career in helping professions like Psychiatric Social Work. It also brings out the question how do we create a job market for Clinical Social Workers or Psychiatric Social Workers in absence of a mandate for policy and programme in Mental Health?
The efforts of Manpower Development in Mental Health for the deficient areas has been a focus of concern at the Mental Health Division in the Ministry of Health and Family Welfare and the NMHP , even though it has yet to transpire to become a concern at the State Govt. levels . This effort trickled down to the Institute in the form of a Scheme for augmentation of Manpower under the NMHP programmes. The department benefitted by way of 2 Psychiatric Social Workers being appointed in June 2010. The number of trained Psychiatric Social Workers in the region got another boost with the joining of a faculty in July 2010.
The department is constantly making efforts to expand its activities and make a meaningful impact in the lives of the persons and families with mentally ill. So, the other major initiative being chartered by the Department of Psychiatric Social Work is the Development of the Rehabilitation department at the Institute. With the NMHP funded Rehabilitation Centre becoming functional in Oct 2010, the department sets back the clock in the history of the Institute. Way long back in 1952 the erstwhile hospital boasted of a highly well organized occupational therapy set-up that closed down due to lack of effort & support from the governing authority.
Currently, the Department has 2 Faculty and 5 Psychiatric Social Workers/ Clinical Supervisors which is a huge improvement from the meager one it had for a decade from 1998- 2008.
The Department faces many hardships in providing the services for which the social work professionals are trained for. It needs to be mentioned here that the challenges the Department faces not only comes from the lesser informed Government officials alone. The other mental health professionals themselves often pose a major problem in the rendering of PSW services. Their lack of acceptance of this profession and their biological orientation often comes in the way of providing adequate PSW services. The current infrastructure of the Institute is such that families do not stay with their wards. This also hampers many of the services that can be effectively provided.
Despite all this, the department functions and has many objectives and future plans that it wishes to fulfill in the years to come.
Objectives of the department is to Provide Psycho-Social assessment towards contribution to the diagnostic & treatment aspect, Undertake psychosocial counseling / case work for patients, their families and significant others, Initiate rehabilitation activities for patients, families &community, Initiate socially relevant activities in the Institute towards creation of welfare & Social services for the mentally ill, Man power Resource development through starting of the teaching programs in Psychiatric Social Work, Contribute as a member of Multi-disciplinary teaching & clinical programmes, Organize community mental health activities, Laison with NGO’s for enlisting support & cooperation for the welfare of the mentally ill, Initiate Research activities
Apart from Teaching/lecturing programs for M Phil and Block/Filed posting students, the Specific Services of department include organizing Workshops / conferences relevant to the discipline and related areas in Mental Health, Psycho-social assessment and counseling, Marital & family counselling, Admission and Discharge Counseling, Organizing group Interaction and Psycho-Education, Initiating and supporting rehabilitation programs, Organizing & supporting community extension programs-Consultancy Initiatives for NGOs, Domiciliary Placement Initiatives for chronic patients, Manpower development through training of professional Social Workers
The Department is slowly making a mark in the NE Region. It has many plans to expand the existing activities. The future plans include Organizing Community extension services at other centers, Starting a Family Treatment Centre, Adolescence Support programs, Organizing disaster Psychosocial care programs, Further laisoning for Integration of Long –stay patients through development of a hospital based Half Way home. The department also plans to conduct an annual workshop for caregivers in an attempt to educate, gain greater acceptance of mental health services and reduce stigma.

CONCLUSION
Establishing and developing Psychiatric Social Work in the North East has been a challenge which one could say has been to a large extent dealt with success. The lack of support from the state governmental, the other members of multidisciplinary teams, infrastructure and facilities has not deterred the growth of Psychiatric Social Work in this region. The authors do feel that establishing a Professional Social Work Council, improving the feeder courses (MSW) and changes within the institute infrastructure and attitude of the other mental health team are needed to have a better impact.

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28th Annual Conference of Indian Psychiatric Society, Assam State Branch at LGBRIMH, Tezpur on 22nd and 23rd September '2018.